Rural Health Unit - ___ BHS; ___________________NAME OF HEALTH CARE FACILITY

Part I

Name: _________________________ Age: ______________ Sex: _______________

Address: ___________________________ PIN: ______________________

( ) PHIC Sponsored IPP Employed ( ) Lifetime

( ) Member ( ) NHTS ( ) LGU ( ) OG ( ) Government

( ) Dependent ( ) NGA ( ) Private ( ) OFW ( ) Private

( ) NON PHIC ( ) Voluntary/Self-Employed

OBLIGATED SERVICESPrimary Preventive Services Frequency Date Performed

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

1. BP Measurements Hypertensive Once a month Non-Hypertensive Once a year2. Periodic Clinical Breast Examination Once a year3. Visual Inspection with Acetic Acid Once a year

DIAGNOSTIC EXAMINATION SERVICES Part I.

Date Diagnosis Type Given Referred Remarks

  

OTHER PCB1 SERVICES

Date Diagnosis Type Remarks

OTHER SERVICESDate Diagnosis Type Remarks

PHILIPPINE HEALTH INSURANCE CORPORATION

Municipal Health OfficeCalasiao, Pangasinan

PCB PATIENT LEDGER

ANNEX A3